In his new book, epidemiologist Ali S. Khan mines his experience on the front lines of infectious diseases to argue for a cool head—and a renewed focus on diseases that we have come to take for granted.
By Elena Gooray
The Next Pandemic: On the Front Lines Against Humankind’s Gravest Dangers. (Photo: Public Affairs Books)
For the last couple of years, it’s felt as though we’re constantly on the edge of another global disease outbreak. In 2014 the bad word was Ebola, which has killed over 11,000 West Africans since the most recent outbreak. Now there is Zika, the mosquito-borne disease believed to cause serious birth defects, which originated in Brazil and has some scientists calling for this summer’s Olympics to be relocated from Rio de Janeiro. Even as the World Health Organization rejected those calls, the virus is spreading. The Centers for Disease Control and Prevention (CDC) has reported 591 cases of Zika so far in the United States.
But 591 represents at most about one-third of Americans who will likely die at the hands of a much more familiar illness: influenza. That fact hints at the dirty little secret at the heart of epidemiologist Dr. Ali S. Khan’s The Next Pandemic: On the Front Lines Against Humankind’s Gravest Dangers: More people die each year from the boring stuff than from the splashier diseases, and when it comes to public-health measures, the boring stuff is what saves us.
Khan’s book delivers this conclusion almost parenthetically, as it does with many of its most interesting arguments. On its face, the book is a detailed tour of the world’s most threatening infectious diseases, which Khan tackled on the ground for more than two decades at the CDC, where he also directed the Office of Public Health Preparedness and Response; these days, Khan serves as dean at the University of Nebraska’s College of Public Health.(Khan’s co-writer is William Patrick, who also co-wrote Sydney Poitier’s memoir.)
Treating a pandemic means talking with people — not just counting them.
The Next Pandemic is full of dramatic material: birds with bacterial infections falling dead from the sky; a government-run bioterrorism simulation actually titled “Operation Dark Winter”; the suicide of Bruce Ivins, an American later named by the Department of Justice as the likely perpetrator of 2001’s anthrax attacks. Khan presents Ivins as an almost slam-dunk suspect for the attacks, which spurred a post-9/11 panic around weaponized bacteria.
Ivins’ guilt is still up for debate, which Khan doesn’t address in any real nuance. But the anthrax chapter stands nonetheless among Khan’s most compelling accounts of the politics and human error that fuel public-health crises: how politicians mired in post-9/11 paranoia and warmongering ignored domestic leads because they assumed international involvement in the attacks; how media outlets like ABC News and the New York Times rushed to support attacker theories that were later discredited; how anthrax powder literally blew through a United States Senate office in Washington, D.C., because after a tainted letter was opened, no one immediately thought to turn off the air conditioning.
Khan was flown in throughout his career to help fix such crises, which inevitably makes his book a hero’s narrative, with a traditional structure: People start dying in patterns, officials like Khan are called in to discern those patterns, local officials get involved, and, if everyone does their job, the dying eventually tapers off. This cycle provides an unnerving glimpse into the daily life of epidemiologists, who devour information so they can make judgments about health crises that develop at such speed and on such a massive scale that concern for individual lives necessarily becomes abstracted, or condensed to numbers. Pandemic’s jacket reviews laud the heroism and savvy of experts like Khan, whose work is certainly invaluable. But what may be most informative from studying their armor of knowledge is identifying the chinks in it.
There is, for example, the risk of over-reliance on data. Khan identifies the need for accurate, meaningful data to explain how an illness that at first resembles a regular fever can transform into an unexpected killer. In fields focused on evidence-based interventions, data is often cast as king. But Khan also describes ways a fixation on data can impede good work, as when health workers passed around inconsistent data on the Ebola outbreak without interrogating it. Creativity and insight, Khan observes, are central to addressing disease threats, and data can only take you so far.
“More data,” in other words, is never more than a partial solution in Khan’s telling, especially in terms of cultural awareness. Here, Khan highlights the importance of efforts to understand and cooperate with local communities when fighting diseases—a response component that boils down to talking with people and not just counting them. At times, Khan explicitly addressesa Western audience, who he takes for granted will disdain “primitive” African customs, such as wanting to wash the bodies of their dead — a practice that sometimes spreads Ebola.
With a few mutations, the flu could become the most devastating virus on the planet.
Writing for that audience leads to sloppy summaries, like: “You can’t blame African villagers for their ignorance or mistrust [toward public-health officials]. They haven’t had a chance. But in the developed world we truly need to get a grip….” This is a facile formulation, and does a disservice to Khan’s more nuanced and telling accounts of Americans mistrusting public-health officials for legitimate reasons. Those accounts include the devastating mishandling of Hurricane Katrina, when officials ignored cultural and economic obstacles in their response plan that disproportionately affected the city’s poor. Khan’s specifics make the clear case for culturally aware public health both inside and outside the U.S., even if his generalities sometimes verge on the patronizing.
A fuzzier question, though, is just how afraid we should be of disease. Though Khan warns against decisions made in panic, he closes the book on a note of alarm: a list of illness categories that are pretty much always at risk of erupting. These include the flu, pneumonia, bugs that travel via medical tourism, viral fevers like Ebola, mosquito-borne viruses like Zika, and sexually transmitted diseases. Most of these are far more commonplace than Zika; the flu, the most familiar, could with a few mutations become the most devastating.
The solution to the danger posed by such unsexy illnesses, according to Khan, is an equally unsexy strategy of preparation. We need to do more to prevent outbreaks rather than wait and respond to emergencies. That means everything from goading resistant poultry farmers into documenting where they are burying disease-ridden birds, to reducing the unnecessary use of antibiotics so we can lower the chances of medicine-resistant superbugs (like the one reported in Pennsylvania last week), to creating worldwide mechanisms for public-health offices to communicate, since diseases travel—now more than ever.
To forestall the next pandemic, Khan suggests, we have to be scared just enough — to prepare, but not to panic. Too often we want public medicine to be a hero’s narrative, but Pandemic unintentionally shows it for what it really is: a constant, imperfect, necessary negotiation of risk.
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